HomeMy WebLinkAboutWAT2025-00010 - WAT Application - 2/27/2025 lob � GOMMUI.aITy
WAT 2.02. - 00010
MASON COUNTY REC&XI '
Public Health & Human Services Shelton:30-427-9670,P.zr 4p
B y'ybrl(ly$ljrAyg7.Ext 400
Application for Determination of Water Ad yJAIY 7 r1 CStrast
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name of Applicant: pdryf i ad Date: ' 1 ` ( LV ZY4
Mailing Address: 9AI' �IQC[ � rsu'p'none: �(s1� -3Sp 'SOII -
Parcel Number: ZZ
Type of Water System Reason for Application
7 Public/Community Water System(2 or more ❑ Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more Phan one residence connecled of water system below if applicable-no
to this well,check the PubliclCommunify Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System I 7 _ U Z
Name of Water System:CDyNUI/IyY�A &D MAfzrq
Water Facility Inventory(WFI)Number Q5-9a13 D (write"none"for two-parry)
'(•{ 1 am the manager of This water system.The water system has been a proved for services.There
are presently 3 connection(s)in use.This wig be the_=connection.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(Le.:recreational to full time). Please indicate on the following line the nature of
this change:
This water system is able and willing to provide water to this (these)connection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager �n52LE / J'/A� Phone 3LP-43Z-78j$
Signature of Water System Manager. '/2' &I.. /p�eeS'��vr� Dale f P
This form may be scanned and available for public view at www.masoncountvwa.00v
J\Em Fonna\Drnhing Water Rteired 05MW2024 Page I or2
Group B Water Systems
Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity test,
a well capacity test, which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source can provide at least 800 gallons per day;and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an ad up
of
water indefinitely in Me future,or guarantee compliance with all applicable WDOE water re so ations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Dete i of
Adequacy for Building permits are satisfied. Additional Grovrth Management requirements may apply. p
36.70A RCW.
❑ Unsatisfactory Determination: ��S0*006M1, �,,�FB1 j O
Applicant's water supply does not appear adequate to meet the needs of Its intended use for M Ibwingfl
reason(s). �J'�,QNN , "K1
qly�(
Reviewer's Signatures:
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountvwa�
Page 2 af2
Nmgwrd Labomlon'
2635 Parkmuol Lc SW
Olympia.WA 98502
360.967 7010
VANGUARD Report of Laboratory Analysis
LAROKATIIRY
CW ed by:
1lawkma WNI Imwnmm M.I,h Drmkmg Wlrtm
3W0 1-5353 Labornom ID: V250219.5
Samp&g Add : Dare Sampkd: 2/182513:30
83 k Community Club Rd Dare Rrc0,ed: 2/19/8&M
Sbchon,WA 99583 Dam Reported: 2i212025
Sample ID: 93 E( mmanily Club Rd
Analyau Result SDRL MCL Unit OF Date Analyzed
Told Co0form&E,.9 by SM 9223B(IDEXX) B kh ID:V250219-5 Amtyeu Ai
('ohlivnt Tmal Ncpti,c I 1 MPNII00nd I MW2517:10
13. ,,I, Ncaati•c I 1 MPNAM0 1 2,19251710
Mirm,by Hach Melhod 10206 Balch ID:V250219.5 Amlyet KS
Mt.wIo,N) AD 0.50 10.00 mg/l. 1 b192516M
Nan
MP.N Mau P.Wbk Nw ,
PPm:Pan•wr wama
oJ.nandnen Revwwcd by Dunin New..L bwamry Dimeta on 02212023
na.nw ygbcabk
SDRL Sue Del¢lml Repmmg Lwn Appmvd by Terri Sobrum,Opnatiom Mvo{or oa 02.)2112025
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wW me DuLn.As,uemne wabTam afVanauwd labwaby.Plux cwle+me Itlwuon�l>aa mauk ha,e ml9wnwra adml me mule.
2635 Parkn nt Ln SW,Suite A Olympia W A 98502 1 Office: 360.%7.7010 1 mamg(avanguaNlabwaory cum
W Wwvwguudlabomtoryxm
loft
WATER FACILITIES INVENTORY (WFI) Quarter. °
Updated: 0311Y2013
�� �, ,,� FORM
O Halth e Printed: On-De 5
ONE FORM PER SYSTEM WFI Punted For: On-Demand
m"MLnvirvn nen/tlIINM
°,WaOl°""L'"s iv°"' Submission Reason: Annual Update
RETURN TO: Central Services-WFI, PO Box 47822, Olympia,WA,98504-7822 Or email wf@doh.wa.gov
1. SYSTEM ID NO. 2. SYSTEM.NAYE a COUNTY 4. GROUP 5. TYPE
05823D COMMUNITY CLUB ROAD 4 PARTY MASON S
6.PRIMARY CONTACT NAME a RWI ADDRESS T.OWNER NAME S MAIUNG ADDRESS
BOBBIE MOSTYN[OWNER] BOBBIE MOSTYN
83 E COMMUNITY CLUB RD 83 E COMMUNITY CLUB RD
SHELTON,WA 98584 SHELTON,WA 98584
STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE
t,
VTTN ATTN
nDDRESS ADDRESS
JITY STATE ZIP CITY STATE ZIP
9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
°nmary Contact Daytime Phone: (360)426-2764 Owner Devlime Phone'. (360)426-2764
3rimary Contact Mobile/Cell Phone: Owner MobllsiGall Phone:
xrimary Contact Evening Phone: Owner Evening Phone:
Fax: E-mail: Fax: E-mail.
1.SATELLITE MANAGEMENT AGENCY-SMA(ebUck only one)
Not applicable(Skip to b12)
Owned and Managed SMA NAME: SMA Number
❑ Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(nmk d*0 apply)
Agricultural ❑Hospital/Glee, Residential
El Commercial I ausiness ❑ Industrial ❑Schott
Day Care ❑Licensed Residential Facility ❑Temporary Farm Worker
Food Serviceil isi Permit ❑Lodging Other(crunch,fire station,etc.):
1,000 or more person event for 2 or more days per year El Recreational I RV Park
MP(.A en
Association F1 County Investor Special District
�CI Li State 75
19 13 17 10 19 20 21 22 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
LIST UTILRMS NAME FOR SOURCE xx
so P ? m 9
2 _
AND WELL TAG ID NUMBER i i < O P m y ^'
°e Example: WELL k1 nZ455 m 4 p w r w1l D n T. ; m O '—i O 5 ><O is
m� y
f p Y
i IF SOURCE ISOR INTERTIESYSTEM r. w c D Si F i O m i7i z reb s i z O z r O 3
q LIST SELLER'S NAME ID i�i In m 2 in re p m m a n m i S O 5 re m r9n r�Z m z
Example: SEATTLE NUMBER r o b w O o P P P y O m 2 z z �. P y z w z F v
S01 WELL 41 NO TAG X X Y X 80 17 SW SW 34 21N 102WI